From the Research
Introduction to Prognosis for Initiating Dialysis for Ultrafiltration (UF) in Patients with End-Stage Kidney Disease (ESKD)
The prognosis for initiating dialysis for ultrafiltration (UF) in patients with end-stage kidney disease (ESKD) is a complex issue, influenced by various factors including the timing of dialysis initiation, residual kidney function, and the patient's overall health status.
Factors Influencing Prognosis
Several factors can influence the prognosis for patients initiating dialysis for UF, including:
- The presence of acute illness or unexplained decline to ESKD, which can lead to higher mortality rates 1
- Cardiovascular disease and sepsis, which are common causes of acute systemic illness and can impact prognosis 1
- The rate of decline in glomerular filtration rate (GFR), which can be greater in patients with acute dialysis starters compared to planned starters 1
- Residual kidney function, which can modify the association between ultrafiltration rate (UFR) and mortality 2
Ultrafiltration Rate and Prognosis
The ultrafiltration rate (UFR) can also impact prognosis, with higher UFRs associated with:
- Higher all-cause mortality 2
- Higher cardiovascular mortality 2
- Rapid decline in residual kidney function (RKF) 2 However, the association between UFR and mortality can be attenuated in patients with higher baseline RKF 2
Timing of Dialysis Initiation
The timing of dialysis initiation is also an important factor, with:
- Early dialysis initiation not associated with a morbidity and mortality benefit 3
- Delaying dialysis until the eGFR is at least as low as 5-7 mL/min/1.73 m2 may be safe in asymptomatic patients with careful clinical follow-up and adequate patient education 3
- The decision to start dialysis should be based on a comprehensive assessment of the patient's symptoms and signs, rather than solely on estimated GFR (eGFR) 3
Treatment Considerations
Treatment considerations for patients initiating dialysis for UF include:
- Finding the right dry weight to minimize volume overload and prevent cardiovascular complications 4
- Minimizing interdialytic weight gain to reduce the risk of hypotension and other complications 4
- Optimizing the target for hemoglobin to reduce the risk of anemia and cardiovascular disease 4
- Lowering dialysate calcium to reduce the risk of cardiovascular disease 4
Conclusion
In conclusion, the prognosis for initiating dialysis for UF in patients with ESKD is complex and influenced by various factors, including the timing of dialysis initiation, residual kidney function, and the patient's overall health status. A comprehensive assessment of the patient's symptoms and signs, rather than solely on eGFR, should be used to determine the optimal timing of dialysis initiation. Treatment considerations, such as finding the right dry weight and minimizing interdialytic weight gain, can also impact prognosis. Further research is needed to determine the optimal timing of dialysis initiation and to improve outcomes for patients with ESKD 5